FY16 Benefits Information Packet - Frederick County Public Schools
Transcription
FY16 Benefits Information Packet - Frederick County Public Schools
Frederick County Public Schools 2015 – 2016 Benefits Information FCPS Benefits Office 191 South East Street 2nd Floor T (301) 644-5080 F (301) 644-5122 Visit http://www.fcps.org/benefits for more information 1 Summary of Benefits Plans UnitedHealthCare Choice Plus Medical Plan UnitedHealthcare Choice Plus allows you to take advantage of two levels of care benefits: • In-network — Selecting a physician or health care provider within the UnitedHealthcare’s large local and national network means maximum coverage and lower out-of-pocket expenses. Copayments are charged for eligible services, and referrals are not required for specialty services. • Out-of-network — Higher deductibles are required and you must file claims for reimbursement of 80% of eligible expenses. Employees have a $200 deductible and an annual out-of-pocket maximum of $1,250. Family coverage requires a $400 deductible and an annual out-of-pocket maximum of $2,500. BENEFITS HIGHLIGHTS IN NETWORK CO-PAYMENTS: Primary Care Physician $20.00 Specialist $30.00 Outpatient Diagnostic Services $20.00 Inpatient Hospital $100.00 Emergency Room (Non-Emergency) $75.00 DEDUCTIBLE: None MAXIMUM OUT-OF-POCKET: No Out-of-Pocket Maximum OUT OF NETWORK CO-INSURANCE: 20% after deductible DEDUCTIBLE: $200 per Covered Person $400 for all Covered Persons in a family MAXIMUM OUT-OF-POCKET: $1,250 per Covered Person per policy year $2,500 for all Covered Persons in a family Out-of-Pocket Maximum includes the Annual Deductible UnitedHealthCare Vision Plan The UnitedHealthcare vision plan offers vision benefits every 12 month. • In-network — Exams and standard lenses paid in full. Adult frame allowance $130.00 Child under age 19 frame allowance $100% coverage to $130, then tiered copay structure. • Out-of-network — Adults are reimbursed according to a fee schedule for exam, lenses and frames. Children under age 19 are reimbursed according to a coinsurance schedule for exam, lenses and frames. AxisPlus Flexible Spending Account Plan AxisPlus offers health/dependent care spending accounts to pay for eligible expenses on a pre-tax basis. • Participating employees will receive an AxisPlus debit card that looks like a credit card and is issued under the MasterCard system and is accepted at specific locations. • Use the debit card to pay for copayments and other qualifying expenses, and there is no more need to file claims for reimbursement from the flexible spending accounts. (It is very important to keep your receipts when using the debit card since you must submit receipts requested under IRS tax rules and regulations.) • A new card will be issued upon initial enrollment and at the expiration date shown on each card. CVS Caremark Prescription Plan Copayments for generic, preferred and non-preferred brand prescription drugs, per the following schedule: 30-Day Supply – Retail 90-Day Mail Order or (Any Retail Pharmacy) 90-Day CVS/Pharmacy (only) Generics $13$21 Preferred brand prescription drugs $25 $45 Non-preferred brand prescription drugs $40 $65 • Maintenance Choice Program – plan participants who take maintenance medications have the choice to purchase their 90-day supply from the mail order program or purchase from a CVS/Pharmacy store and pay the same mail order copayment. • Mandatory generics when available as well as mandatory specialty pharmacy program for specialty prescription drugs. • Diabetic Meter Program – plan participants with diabetes may qualify for a free blood glucose meter when diabetic testing supplies are ordered through the mail order program. Delta Dental Plan Dental coverage will be offered solely through Delta Dental, at three levels: Delta PPO — You receive in-network benefits with no deductible, no forms to file and lower copayments. Delta Premier — You are responsible for copayments and a deductible. Out-of-network — You have a deductible to satisfy and need to file claims for reimbursement. Standard Plan: $1,000 maximum benefit per covered person Buy Up Plan: $2,000 maximum benefit per covered person 2 2015 – 2016 Benefits Information AxisPlus, the New Flexible Spending Account Provider: UnitedHealthcare Pilot Medical Necessity Program: • Effective July 1, 2015, AxisPlus is the new Flexible Spending Account (FSA) provider • Effective July 1, 2015, certain services, tests or procedures must be pre-authorized through the Medical Necessity Process for the Choice Plus Plan • AxisPlus will process medical and dependent care claims for expenses incurred for plan year beginning July 1, 2015 • Generally, when seeking services from a UnitedHealthcare network provider, your network provider will facilitate the Prior Authorization process for you • Employees who enroll in this plan will receive an AXISPlus debit card to pay for eligible expenses • Employees and covered dependents who receive certain services from out of network providers are responsible for obtaining the Prior Authorization by contacting UnitedHealthcare • You must enroll in the FSA every year. You may enroll in this plan through Employee Self Service CVS Prescription Plan Programs: • Generic Step Therapy – effective July 1, 2015, you and covered dependents will be required to try generic alternatives first in certain therapeutic classes before brand name drugs will be covered • Additional information about the Medical Necessity Program can be found on page 14 of this packet • Detailed information on the services that will require Prior Authorization will be provided in the Summary Plan Description once it is updated for July 1, 2015 • If you choose to stay on your current, higher cost brand name medication, you may have to pay the full price if you have not tried a generic option to treat your health condition “Grandfathered Status” Frederick County Public Schools (FCPS) has elected to be a “grandfathered health plan” under the Patient Protection and Affordable Care Act. As permitted by the Affordable Care Act, a “grandfathered health plan” can preserve certain basic health coverage that was already in effect when the law was enacted. As a “grandfathered health plan,” FCPS is not subject to certain consumer protections of the Affordable Care Act that may apply to other plans. • Additional information about Generic Step Therapy can be found on page 13 of this packet • Effective July 1, 2015, compound drugs will require a prior authorization to be covered by the prescription benefit plan • A compound drug is made by combining, mixing, or altering ingredients to create a customized medication that is not otherwise commercially available Summary of Benefits and Coverage To comply with the Patient Protection and Affordable Care Act (the Affordable Care Act), Frederick County Public Schools provides a Summary of Benefits and Coverage (“SBC”). The SBC can be found at the school system’s website, www.fcps.org/benefits and paper copies are available upon request. The SBC is intended to be educational in nature. Complete details can be found in the insurance companies’ documents and the plan’s legal documents, which will always govern in case of a dispute. • For select specialty drugs prescribed on or after July 1, 2015, you may be required to try a preferred product prior to the non-preferred medication being dispensed • Contact CVS Customer Service, 1-866-260-4646 if you have questions or need additional information about the new prescription drug programs NOTE: The premium rates and benefits included in this material are contingent upon final contract negotiations with FCTA, FASSE, FCASA and final adoption of the Board of Education’s Fiscal Year 2016 budget. 3 JULY 1, 2015 – JUNE 30, 2016 FREDERICK COUNTY PUBLIC SCHOOLS EMPLOYEE BENEFITS AND INSURANCE SUMMARY FY16 PAYROLL DEDUCTIONS – EACH PAY PERIOD* INFORMATION ABOUT INSURANCE: • MEDICAL • PRESCRIPTION • DENTAL SUBJECT TO CHANGE FOR 2015-2016 PLAN YEAR* HEALTH INSURANCE** UnitedHealthcare Medical, UnitedHealthcare Vision, CVS CareMark Prescription EMPLOYER’S CONTRIBUTION (How much FCPS pays on your behalf) 10-Month Employees 11-Month Employees 12-Month Employees $20.50 $18.63 $17.08 Employee + One Dependent*** $154.43 $140.39 $128.69 Dental – $28.81 per month ($345.72 per year) Employee + Family**** $204.14 $185.59 $170.12 Dependent Coverage Employees + Family**** $42.17 $38.34 $35.14 Medical – $576.79 per month ($6,921.48 per year) Employee Only (both parents employed by FCPS) Employee Coverage Medical – $644.96 per month ($7,739.52 per year) DENTAL INSURANCE** Standard Delta Dental $1,000 Maximum Benefit Per Covered Person DENTAL INSURANCE** Buy Up Delta Dental $2,000 Maximum Benefit Per Covered Person 10-Month Employees 11-Month Employees 12-Month Employees 10-Month Employees 11-Month Employees 12-Month Employees Paid 100% by FCPS Paid 100% by FCPS Paid 100% by FCPS $3.66 $3.33 $3.05 Employee + One Dependent*** $36.32 $33.02 $30.27 $47.67 $43.34 $39.73 Employee + Family**** $42.04 $38.21 $35.03 $54.58 $49.61 $45.48 Employees + Family**** $24.75 $22.50 $20.63 $37.28 $33.89 $31.07 Employee Only (both parents employed by FCPS) *Payroll deductions are contingent upon final contract negotiations with FCTA, FASSE and FCASA and final adoption of the Board of Education’s Fiscal Year 2016 budget. **Contributions for medical and dental insurance coverage are deducted from your gross earnings before taxes are calculated. ***In this context, “Employee + One Dependent” would refer to employee + spouse or employee + dependent. ****In this context, ”Family” refers to two or more dependents. This publication is intended to provide an overview of FCPS benefits; complete details can be found in the insurance companies’ documents and the plans’ legal documents, which will always govern in case of a dispute. The Board of Education of Frederick County, FCTA, FASSE and FCASA jointly reserve the right at any time to modify or amend, in whole or in part, any or all plan provisions. 4 INSURANCE COMPANY CONTACT INFORMATION Plan/Contact Health/Vision Insurance Address Phone & Website UnitedHealthCare Main Contact: UnitedHealthcare 800 Oak Street Frederick, MD 21703 Claims Office: P.O. Box 740800 Atlanta, GA 30374-0800 Phone: 1-877-702-5116 www.myuhc.com UnitedHealthCare Vision P.O. Box 30978 Salt Lake City, UT 84130 Customer Service: 1-800-638-3120 Provider Locator: 1-800-839-3242 www.myuhcvision.com One Delta Drive Mechanicsburg, PA 17055 Phone: 1-800-932-0783 www.deltadentalins.com Dental Insurance Delta Dental Flexible Spending Accounts AxisPlus 860 East 9085 South Sandy, UT 84094 Phone: 1-877-872-2125 www.myaxisplus.com CVS/CareMark Claims Office P.O. Box 52010 Phoenix, AZ 85072-2010 Phone: 1-866-260-4646 www.caremark.com CVS/CareMark Mail Order P.O. Box 94467 Palatine, IL 60094-4467 Fax: 1-800-323-0161 Prescription Plan FCPS BENEFITS OFFICE CONTACT INFORMATION Contact Email Phone Number Benefits Office 301-644-5080 Colette Baker [email protected] 301-644-5112 Phoebe Barreto [email protected] 301-644-5085 Kimberly Schaub [email protected] 301-644-5115 Shannon Thompson [email protected] 301-644-5093 Doris Toms [email protected] 301-644-5052 FOR BENEFITS INFORMATION AND FORMS YOU MAY USE THE FCPS WEBSITE http://www.fcps.org/benefits UNITEDHEALTHCARE SUMMARY PLAN DESCRIPTION and DELTA DENTAL INFORMATION SHEETS CAN BE FOUND AT insidefcps The HIPAA Privacy Rules require health plans to provide a Notice of Privacy Practices to persons covered under the health plan. Eligible employees may obtain a copy of the Notice of Privacy Practices by visiting the school system’s website: www.fcps.org. Go to Departments, Human Resources, Benefits Links & Forms, HIPAA Privacy Statement. Employees may also contact the school system’s Benefits Office for a copy of the privacy practice notice. Questions concerning the HIPAA Privacy Rules may be directed to: Frederick County Public Schools Colette Baker, Senior Manager, Benefits 191 South East Street, Frederick, MD 21701 5 Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2015. Contact your State for more information on eligibility – ALABAMA – Medicaid Website: www.myalhipp.com Phone: 1-855-692-5447 NEW JERSEY – Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 ALASKA – Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 NEW YORK – Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 COLORADO – Medicaid Medicaid Website: http://www.colorado.gov/hcpf Medicaid Customer Contact Center: 1-800-221-3943 NORTH CAROLINA – Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 FLORIDA – Medicaid Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268 NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604 GEORGIA – Medicaid Website: http://dch.georgia.gov/ Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150 OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 INDIANA – Medicaid Website: http://www.in.gov/fssa Phone: 1-800-889-9949 OREGON – Medicaid Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075 IOWA – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 PENNSYLVANIA – Medicaid Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462 KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 800-792-4884 RHODE ISLAND – Medicaid Website: www.ohhs.ri.gov Phone: 401-462-5300 KENTUCKY – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 SOUTH CAROLINA – Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 6 LOUISIANA – Medicaid Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447 SOUTH DAKOTA – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059 MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-977-6740 TTY: 1-800-977-6741 TEXAS – Medicaid Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493 MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120 UTAH – Medicaid and CHIP Medicaid Website: http://health.utah.gov/medicaid CHIP Website: http://health.utah.gov/chip Phone: 1-866-435-7414 MINNESOTA – Medicaid Website: http://www.dhs.state.mn.us/id_006254 Click on Health Care, then Medical Assistance Phone: 1-800-657-3739 VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005 VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282 MONTANA – Medicaid Website: http://medicaid.mt.gov/member Phone: 1-800-694-3084 WASHINGTON – Medicaid Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/ index.aspx Phone: 1-800-562-3022 ext.15473 NEBRASKA – Medicaid Website: www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 WEST VIRGINIA – Medicaid Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability NEVADA – Medicaid Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900 WISCONSIN – Medicaid and CHIP Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002 NEW HAMPSHIRE – Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 WYOMING – Medicaid Website: http://health.wyo.gov/healthcarefin/equalitycare Phone: 307-777-7531 To see if any other states have added a premium assistance program since January 31, 2015, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsawww.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 OMB Control Number 1210-0137 (expires 10/31/2016) 7 FREDERICK COUNTY PUBLIC SCHOOLS DEPENDENT ELIGIBILITY DOCUMENTATION REQUIREMENTS RELATIONSHIP TO EMPLOYEE SPOUSE DOCUMENTATION FOR VERIFICATION OF RELATIONSHIP ELIGIBILITY DEFINITION A person to whom you are legally married Provide all of the following: • Copy of official marriage certificate • Copy of most recent Federal Tax Form (1040 or 1040A)* that identifies employee-spouse relationship (1st page only & black out financial information) *If marriage occurred in current year, Tax Form is not needed. DEPENDENT CHILD(REN) • Dependent children until they reach age 26 Natural Child: • Copy of child’s official state birth certificate Step Child – Provide all of the following: • Copy of child’s official state birth certificate (must name spouse of employee as the child’s parent) • Copy of official marriage certificate • Copy of most recent Federal Tax Form (1040 or 1040A)* that identifies employee-spouse relationship Legal Ward or Court Appointed Guardianship – Provide all of the following: • Copy of dependent’s official state birth certificate • Copy of legal ward court document, with presiding judge’s signature and seal Adopted Child: • Copy of official adoption papers, must indicate child’s date of birth Child for whom the court has issued a QMCSO • A copy of the Qualified Medical Child Support Order DISABLED DEPENDENTS • Unmarried dependent children over the age limit if: 1. They are dependent on you for primary financial support and maintenance due to a physical or mental disability 2. They are incapable of selfsupport 8 Provide all the following: • Completed Disability Form (Request from Benefits Office) • Copy of most recent Federal Tax Return BENEFITS Medical and Dependent Care Flexible Spending Section 125 Cafeteria Plan WHAT IS FLEXIBLE SPENDING? A Flexible Spending Account (FSA) is an IRS program which allows participants to pay for qualified Medical and Dependent Care expenses with pre-tax dollars. HOW DOES AN FSA WORK? During your employer’s open enrollment you estimate your expenses and make an annual election amount. Uniform throughout the plan-year and are contributed to your FSA. When you incur expenses simply swipe your AxisPlus® debit card, or file a reimbursement claim with AxisPlus Benefits™, and we’ll reimburse you directly from your FSA. WHAT TYPES OF FSA S ARE AVAILABLE? There are three types of FSAs: Health/Medical, Dependent Care and what’s called a Limited FSA. The Medical FSA covers out-of-pocket medical, dental, and vision expenses.* The Dependent Care FSA reimburses dependent care related expenses such as child daycare. Because they are two separate accounts, money cannot be exchanged between them. The Limited FSA exclusively reimburses for out-of-pocket dental, vision or preventative care expenses. Limited FSAs work well with Health Savings Accounts. *See the Common Eligible Medical Expenses list on page 4. 9 AxisPlus Benefits™ | p 3 WHAT deductions are made from each paycheck (pre-tax) Cafeteria Plan At A Glance Frederick County Public Schools One of the many benefits of being employed with Frederick County Public Schools (FCPS) is that you have access to a Cafeteria Plan established by FCPS. A Cafeteria Plan allows you to pay for out-of-pocket medical expenses. The major advantage of FCPS’s Cafeteria Plan is that, by participating, you save money by paying for benefits you would normally pay for but you avoid having to pay Federal Income and Social Security taxes. If you do participate in the Cafeteria Plan you would not be eligible for a Federal income tax credit on your next tax return. FCPS’s Plan Information Plan Name: Frederick County Public Schools Address: 191 South East St. Frederick, MD 21701 Telephone: (301) 644-5112 Plan Number: 125 Plan Year Begin: July 1 Amended: N/A Plan Year End: June 30 Maximum Health FSA Limit: $2500 Maximum Dependent Care Limit: $5000 Annual Rollover Maximum: $500 Grace Period: No Run-out Period: 90 days for active employees and terminated employees to newly hired employees or those with special circumstances (see Summary Plan Document). For mid-year enrollments, participation will begin on the 1st of the month following hire date. Beginning and Ending of Coverage The coverage will begin the first day of the Plan Year for those who enroll during the open enrollment period. For mid-year enrollments the coverage date will begin as set forth by FCPS (see eligibility). The coverage will end at the end of the month of the termination date, or at the end of any applicable run-out/carryover period. This plan is subject to COBRA (see the Summary Plan Description for more details). Benefits Available The FCPS Cafeteria Plan offers the following benefits: Health Flexible Spending Account A Health Flexible Spending Account (FSA) allows you to get reimbursed for qualified medical expenses with pre-tax funds (see Section 213D and Section 105 of the Internal Revenue Code for list of eligible expenses. You cannot use your FSA for expenses that have been paid by your medical insurance plan.) The maximum annual election amount is $2500. Dependent Care Flexible Spending Account Plan Administrator: FCPS Service Provider: AxisPlus Benefits Service Provider Contact: Lacey Johnson The Dependent Care Flexible Spending Account (DCAP) allows you to be reimbursed for qualified dependent day-care expenses with pre-tax funds. The maximum annual election amount is $5000 (married filing jointly or head of household) or $2500 (married filing separately). To be eligible for reimbursement you will need to provide a statement from the service provider with the following information: name, address, taxpayer identification number (in most cases), and incurred expense amount. Please see the Summary Plan Description for dependent eligibility requirements. Elections Reimbursement It is important for you to decide what benefits you will need for each Plan year. Your decision should be carefully made based on your expected health expenses for the coming year. Throughout the Plan year you can submit for reimbursement for qualified medical and dependent care expenses in the following ways: fax (forms available at myaxisplus. com), email, online, or mobile application. Employees may also pay for their qualified medical expenses directly from their FSA with the AxisPlus debit card. See the SPD for further details. Unless a qualifying “change in status” event occurs, you will not be able to change your elections after the first month of the Plan year. To see a list of the qualifying “change in status” events please see your Summary Plan Description. Eligibility Open enrollment will take place each year prior to the start of the Plan year. After the Plan year begins enrollment is limited Expenses are “incurred” when the service has been provided. The reimbursement requirements will be listed on the reimbursement claim forms. For Health FSA and DCAP accounts reimbursement claims must be submitted no later than 90 days after the end of the Plan Year. Any Health FSA funds exceeding $500 10 left over after the 90 day run-out period will be forfeited. See “Rollover” section below for additional details. Non Discrimination Per compliance with the various rules and regulations of the Internal Revenue Code the election amounts of “highly compensated employees” and “key employees” (officers, shareholders or highly paid employees) may be limited due to non-discrimination regulations. For more information please see the Summary Plan Description. Family and Medical Leave Act (FMLA) If you go on a qualifying FMLA Leave this plan will comply with the rules and regulations set forth in the proposed Regulation 1.125-3 as well as any additional policies established by FCPS. Please see the Summary Plan Description for more details. Rollover Under the new IRS regulations, employees will be able to rollover up to $500 of their Health FSA funds from one Plan year to the next. The rollover funds will be available to employees for one additional year. Any amount rolled over will not affect the election amount for the new Plan year. Any funds above $500 left over after the 90 day runout period will be forfeited. Flexible Spending Frequently Asked Questions What is a Flexible Spending Account (FSA)? Flexible Spending is an employer sponsored program that allows you to set aside money pre-tax to use for certain IRS eligible expenses. The Medical FSA covers not only medical expenses, but also dental and vision services. How does an FSA work? During the open enrollment period with your employer, you will make an election for the amount you want contributed to your FSA. That annual amount will be divided equally over your yearly pay schedule, and deductions will be made pretax from each pay check and deposited to that account. As you incur expenses, you will submit for reimbursement from your account, either with a paper claim or with the AXISPlus debit card. What are the advantages to having an FSA? When you participate in the Flexible Spending program, your eligible expenses are paid for with tax-free money. Also, as the contributions are withheld from your paycheck pre-tax, it lowers your taxable income, meaning you pay less in taxes, and take more money home. What are considered eligible expenses? There are 3 things to consider as you determine whether an expense is eligible for reimbursement from your Medical FSA – services, service dates, and eligible dependents. Services- Eligible medical expense are defined by IRS Code §213(d) and must not be excluded by the plan documents. In order to qualify for reimbursement, the expense must diagnose, cure, mitigate, treat, or prevent disease, or affect a structure or function of the body. Expenses aimed at maintaining general health or improving a person’s appearance (cosmetic procedures), are not considered eligible expenses. Service Dates- In order to be eligible for reimbursement, services must be provided/incurred during the time that you are covered and active under the plan. The IRS is concerned with the actual date of service, not the date of payment. Eligible Dependents- Coverage for a Medical FSA is extended to the employee, the employee’s spouse, and the employee’s child who is under age 26 or someone else who is a qualified tax dependent of the employee. When can I enroll? You may enroll in the plan during your employer’s open enrollment period prior to the start of the plan year. You may also enroll mid-year if you are a newly hired employee, or if you have a qualified Status Change Event as outlined in the Summary Plan Description. Can I make changes to my account mid-year? Once you make your election during the enrollment period, it cannot be changed or cancelled during the plan year, it is irrevocable. Exceptions to the irrevocability rule are allowed mid-year with a qualified Status Change Event such as a marriage, divorce, birth, adoption, death, etc. The election changes must be consistent with the status change. What if my spouse has a Health Savings Account? If your spouse is participating in a Health Savings Account (HSA), participation in this FSA may disqualify them from further contributions to that HSA. What happens to money left in the account at the end of the plan year? Under new IRS regulations, employees are now able to rollover up to $500 of their Health FSA funds from one plan year into the next. This will allow participants an additional 12 months to spend the remaining balance. Funds that are rolled over will not affect election amounts for the new plan year. A Run-out period will still be applicable, allowing you time to submit reimbursement claims for expenses incurred prior to the end of the plan year. Rollover does not apply to the Dependent Care FSA. Do I have to wait for the money to be deposited before requesting reimbursement? With a Medical FSA, you do not have to wait for the deposits to be made before requesting reimbursement. Your full annual election amount is available to you on the first day of the plan year. 11 Flexible Spending Frequently Asked Questions Cont. What information do I need for reimbursement? In order to verify the eligibility of an expense, we need a third party statement indicating the provider’s name and contact information, the patient, the date of service (not the date of payment), a description of services rendered, and your portion of the expense. You should also retain a copy of the statement for your records. How do I submit a reimbursement claim and when can I expect payment? Reimbursement claims may be submitted electronically with the “Online Claims Entry” option on your account through www.myaxisplus.com. Reimbursements may also be submitted with a printed reimbursement claim form and sent to our office via email, fax or postal service. Reimbursement claims will be processed daily. Where can I find out my account information and balance? As a participant, you will have access to a secure online account through www.myaxisplus.com. Here you will be able to view your account history and balance, submit reimbursement claims electronically, view eligible expenses lists, print various forms and documents, and much more. You will be provided the online registration information after enrollment. AXISPlus Debit Card What is the AXISPlus debit card? The AXISPlus debit card is a MasterCard® debit card that offers you direct access to your FSA funds. How does it work? You may swipe your AXISPlus card as you would any other debit card at a qualified medical merchant. The merchant must accept MasterCard® as a form of payment. The funds will be debited from your Flexible Spending Account and paid directly to the service provider. Where can I use it? The use of the AXISPlus card is limited to providers with a qualified medical Merchant Category Code (MCC). These include doctor’s offices, hospitals, pharmacies, dental offices, and vision clinics. The card will not be accepted at an ATM or for cash back on a purchase. What if I lose my card? From your account on www.myaxisplus.com you have the capabilities to report your AXISPlus debit card as lost or stolen and to order a replacement card. Can I have additional cards? All enrollees will automatically be issued one debit card at the start of participation in flexible spending. Any additional or replacement cards my be ordered through AxisPlus Benefits. Will I need to send in any paper work? Under the IRS regulations, we are required to verify the eligibility of every expense, whether paid with a reimbursement claim or the AXISPlus debit card. There are various check-point systems in place to greatly reduce the amount of documentation you will be required to submit to our office as you use the debit card, but it does not eliminate the need for paper work entirely. The information requested will be the same as that of a reimbursement claim (see What information do I need for reimbursement? above). For each card swipe, you will receive automatic email notifications. These notifications will inform you of the status of the transaction, and whether or not additional information/documentation is being requested. What happens if a card payment is ineligible? If all or a portion of your AXISPlus debit card transaction is deemed ineligible, you will be required to pay back the ineligible amount to your Flex account. This can be done in a variety of ways and our staff will help you find the option best suited for you. Please be aware that while there is money due on your account, your debit card will be temporarily suspended until all transactions are either paid back or resolved. 12 Generic Step Therapy & You Your first step on the path to better health for less Welcome to the CVS Caremark Generic Step Therapy program. This program helps you and your doctor choose a lower-cost, generic medicine as the FIRST STEP in treating your health condition.* Just because a medicine costs more doesn’t mean it works better. Some health conditions have many treatment options that vary in cost. Generic Step Therapy helps make sure the medicines that are effective and priced right are used first.* It makes sense to try a generic medicine as the first step in treating your health condition. Why? Because for many people, they work just as well as other medicines but can cost up to 80 percent less.** With Generic Step Therapy, if you choose to stay on your current, higher-cost brand-name medicine, you may have to pay the full price if you have not tried a generic option to treat your health condition.† For some health conditions, you may have to try two generic options, depending on your plan. Why pay more to treat your condition when a generic medicine may provide the same health benefits for less?‡ Remember, lower cost does not mean lower quality. Choose a generic medicine and treat your health condition for less! How Do You Take The First Step? STEP 1 Talk to your doctor to find out which lower-cost, generic options may be right for you STEP 2 Ask your doctor to call in your new prescription(s) to: • Retail pharmacy: Find one included in the CVS Caremark Network at www.caremark.com • CVS Caremark Mail Service Pharmacy: Your doctor can fax, e-prescribe or call toll-free at 1-800-378-5697 STEP 3 Fill your new prescription(s) and treat your health condition for less!‡ Want To Learn More? Learn more about Generic Step Therapy by watching this short video: www2.caremark.com/ sitetour/steptherapy/. You can also visit Caremark.com and click “Find Savings and Opportunities” OR call the toll-free number on the back of your prescription ID card. We are ready to help! *Lower-cost options are generally generic medicines. ** Generic Pharmaceutical Association website: http://www.gphaonline.org/about-gpha/about-generics/case. † Your doctor can contact CVS Caremark to request a prior authorization if you have a unique medical situation that requires you to keep taking the higher-cost (brand-name) medicine. If you have previously taken generic medicine in the same drug class, you may not be affected by this change. ‡ Your savings will vary based on your plan and/or medicine prescribed. ©2013 Caremark. All rights reserved. 5295-28807a 080613 Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. 13 Medical Necessity Frequently Asked Questions We believe that both members and providers (physicians and other health care professionals, hospitals and clinics) can be supported in making informed health care decisions by sharing information about what services, tests or procedures are considered clinically appropriate in accordance with Generally Accepted Standards of Medical Practice. UnitedHealthcare offers both members and providers this information, based on credible scientific evidence published in peer-reviewed medical literature and generally recognized by the relevant medical community, through the Medical Necessity process. With this information, we seek to support you and your doctor as you decide what steps to take. Q1: What is medical necessity? A1: Based upon a foundation of evidence-based medicine, Medical Necessity is the process for determining benefit coverage and/or provider payment for services, tests or procedures that are medically appropriate and cost-effective for the individual member. The Medical Necessity process: Provides an opportunity to address covered services at the individual level to support enhanced access to quality care for the member. Utilizes generally accepted standards of good medical practice in the medical community. Offers communication between health plans, members and providers, allowing for prospective, concurrent and retrospective review as well as appeal rights for adverse determinations. Q2: What are the benefits of determining whether a service is medically necessary? A2: Medical Necessity uses advancements in medical practice standards based on scientific evidence and Generally Accepted Standards of Medical Practice. Medical Necessity is designed to combine these advancements in health information technology to address differences in care and promote efficient delivery of high quality care in a cost-effective manner. Q3: What is prior authorization? A3: Prior Authorization is the process of determining benefit coverage prior to a service being rendered to an individual member. A determination is made based on Medical Necessity criteria for services, tests or procedures that are appropriate and cost-effective for the member. This member-centric review evaluates the clinical appropriateness of requested services in terms of the type, frequency, extent and duration of stay. 14 Q4: How is Prior Authorization different from the current Care Coordination process in some UnitedHealthcare plans? A4: Going forward, coverage determinations for those members on the appropriate benefit plan will use Medical Necessity criteria. To support this change, we are introducing language in our new Certificates of Coverage and Summary Plan Descriptions which expands the definition of a covered service as one that is medically necessary. Services determined to be not medically necessary during the pre-service review process will be the member’s liability (assuming a determination of non-coverage was rendered and communicated prior to the date of service and a specific member attestation is on file with the provider). Q5: Where can I find the requirements for services and procedures that require Prior Authorization? A5: Prior Authorization requirements will be listed in the Certificate of Coverage and Summary Plan Description. Q6: How are the services outlined in the UnitedHealthcare Prior Authorization requirements selected? A6: The Prior Authorization requirements reflect those services where data demonstrates significant variation in care being delivered and the clinical efficacy of the treatment. Q7: What clinical criteria will UnitedHealthcare use to determine Medical Necessity? A7: UnitedHealthcare uses Generally Accepted Standards of Medical Practice, which are based on credible scientific evidence published in peer-reviewed medical literature and are generally recognized by the relevant medical community. We may also use standards that are based on physician specialty society recommendations or professional standards of care, or other evidence-based, industry-recognized resources and guidelines, such as the Milliman Care Guidelines®, to determine Medical Necessity and appropriate level of care. Q12: When am I responsible for the cost of services? A12: You are responsible for the cost of services in the following situations: 1. The service is deemed not covered or not medically necessary in accordance with your benefit plan, and the determination was communicated before the service was rendered and you have given your provider an attestation acknowledging your responsibility for the service. 2. You were responsible for obtaining Prior Authorization, but failed to do so. 3. During an inpatient (overnight) stay in a hospital or facility, an inpatient day is determined to be custodial. Custodial care includes any of the following services: Q8: Who is responsible for obtaining Prior Authorization? A8: Generally, members in plans with Prior Authorization (e.g., Choice, Choice Plus, Navigate) can rely on their network physician to obtain Prior Authorization for services on the standard Prior Authorization requirements list. Members will be responsible for obtaining Prior Authorization if they access a non-network provider, are in a product accessing our Options PPO network (i.e., Options PPO, Non-Differential PPO), or if the service is on a customer-specific (non-standard) Prior Authorization requirements list. •Non-health-relatedservices,suchasassistancein activities of daily living (examples include feeding, dressing, bathing, transferring and ambulating). •Health-relatedservicesthatareprovidedforthe primary purpose of meeting the personal needs of the patient or maintaining a level of function (even if the specific services are considered to be skilled services), as opposed to improving that function to an extent that might allow for a more independent existence. Q9: What should I do before receiving services that require Prior Authorization? A9: 1. Contact UnitedHealthcare to request Prior Authorization if you are responsible for obtaining Prior Authorization (see Question and Answer above). •Servicesthatdonotrequirecontinuedadministration by trained medical personnel in order to be delivered safely and effectively. 2. Review your Prior Authorization letter to make sure the services that are approved are the same as those you are expecting to receive and confirm this with your provider. Q13: Are there any changes to the appeal process? A13: UnitedHealthcare will continue to adhere to all applicable federal and/or state appeal requirements for members. Q10: What process should I follow to obtain Prior Authorization? A10: Your Certificate of Coverage or Summary Plan Description sets forth the process you should follow for benefits that are subject to the Medical Necessity Prior Authorization process. Q14: Who can I contact if I have more questions? A14: Please call the Customer Care number on your health plan ID card. Q11: How will I be notified of the outcome of a Prior Authorization request? A11: UnitedHealthcare will mail a letter to you and your physician for all Prior Authorization requests. If a non-coverage determination is rendered, an Adverse Benefit Determination letter will be generated and will include an explanation for the determination, criteria used and appropriate internal appeal and/ or external review rights. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by UnitedHealthcare Insurance Company, United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through a UnitedHealthcare company. 100-10959 10/11 © 2011 United HealthCare Services, Inc. 15